Photovoice is a visual action research technique through which communities can share their problems, barriers and challenges with policy makers using photographs and narrative. In the Indian Sundarbans - the world’s largest active mangrove delta and home to close to five million people – this technique has been utilized by a large number of women to make waves in policy circles in these remote islands.

Children in the Indian Sundarbans suffer from chronic malnutrition, coupled with a high prevalence of easily preventable but highly communicable diseases. Furthermore, children’s access to public health facilities in the region is a challenge, exacerbated by the rough terrain and the winding tidal rivers of the deltaic region. Recent increases in intensity and periodicity of climatic shocks, such as flooding and cyclones, threaten to tip the balance and create an even more difficult health situation for all – especially children – in the Sundarbans.

This ferry landing (ghat) has been broken for last three months. This is the only way to cross the river. The mainland, where the nearest Public Health Centre is located, is on the other side. Photographer: Sita Das (Jayasree Colony, G-plot)

Future Health Systems (FHS) researchers from the Indian Institute of Health Management Research (IIHMR) have been working with women of the Sundarbans to use Photovoice to empower marginalized recipients of health services in an effort to create positive change. The technique uniquely communicates life's narratives evocatively with scientific rigor which appeals to both the academic and the non-academic alike, including policy managers. This unique participatory action research method is being conducted to understand the demand-side perception of health issues through the eyes of the women islanders regarding prominent social factors that directly or indirectly determine the health of their children in the geo-climatically challenged Sundarbans.

This method seems to supersede traditional methods of facilitated discussion to visually capture the needs assessments for a community as a standard part of the technique. It also offers an alternative pathway for individuals to come together and reveal their concerns to influence public policy on issues like erosion, breaching of embankments, loss of productivity due to salinity ingress, depleting natural resources and the resulting migration, accessibility, acceptability and affordability of the existing health system which ultimately determine the health of the islanders.

Over 80 women participants with at least one child between 0-6 years of age took 467 photographs to document the social factors affecting the health of their children. In the fortnightly group meetings facilitated by FHS researchers in the course of the photovoice research, participants identified general health problems with a focus on physical disability, mental health problems and non-communicable diseases. Under the issue of maternal and child health, respondents mostly documented service delivery issues and unhygienic practices, along with social issues such as early age marriage, and pregnancy related issues like physical stress during pregnancy and recurrent deliveries.

The determinants that featured prominently included:

Food insecurity and related malnutrition among the children

Livelihood

Shelter and embankments

Water and sanitation

Poor health care services

Accessibility

General health and hygiene awareness

Climate.

To discuss the issues they thought needed to be solved urgently, the women islanders then led face-to-face interaction with policy makers at three levels: Local decision makers at the community level, such as Panchayat members, CBO/NGO personnel, community leaders, grass root public health factionaries; Block level decision makers, like Gram Panchayat heads, Block Development Officers, local media personnel, donor agency representatives; and State level decision makers like Ministers, mainline media, senior bureaucrats and representatives of international donor agencies. As part of the technique, participants presented a photovoice exhibit to the policy makers which visualized respective issues.

As a result of the interaction with policy makers at various levels, some positive changes have been made, including:

Road infrastructure is being revamped to increase accessibility to public health facilities.

24 hour medical care is available in the primary health centre.

The elected head of the Panchayat at the block level has voluntarily offered to support and facilitate dissemination of visual research evidence with the agricultural, women and child health, and water supply departments at the sub divisional and the district level.

There is a growing demand from key community stakeholders for photovoice research on supplementary issues linked to health. Community-level policy dialogues and the opportunities for forward linkages have also added value to the research uptake process.